2018 Plan Highlights |
Co-pay/Co-insurance |
|---|---|
IN=In-Network, OUT= Out-of-Network |
|
Monthly premium with prescription drug coverage |
$155 |
Gold PPO with Part D monthly premium for EPIC subsidy members (Assumes EPIC premium assistance) |
$116 |
Annual out-of-Pocket Max for your protection (once met, MVP pays 100% of covered services) |
$6,000 IN, $10,000 combined IN and OUT, excluding acupuncture, and Part D drug costs |
PCP co-pay |
IN - $15 / OUT - $60 |
Specialist co-pay |
IN - $50 / OUT - $60 |
Inpatient Hospital co-pay |
IN - $350/day for days 1-5; $0 for days 6+ |
Emergency Room Care (Worldwide Coverage) |
$80 |
Urgently Needed Care (Worldwide Coverage) |
$50 |
| Lab | $10 OUT 40 % co-insurance |
X-rays |
IN - $50 / OUT - $60 |
| Other radiology services (CT scan, PET scan, MRI) | IN - $100 / OUT - 40% co-insurance |
Skilled nursing facility |
IN - $0/day for days 1-20, |
Outpatient services co-pay |
IN - $250 Ambulatory Surgery $500 Outpatient Hospital |
Home care |
IN - covered in full |
Diabetic blood glucose test strips |
IN- 10% co-insurance for OneTouch, FreeStyle, and Precision brands OUT - 40% co-insurance
|
Out of network coverage |
No deductible; $60 office visit; 40% co-insurance for most other services; out-of-pocket protection applies |
| TruHearing® Hearing Aid Benefit | $499 or $799 co-pay per aid Up to two aids per year |
$75 reward per year |
|
SilverSneakers® fitness program - fitness center membership benefits |
|
| myVisitNowSM Access 24/7 online doctor visits using a computer, tablet, or smart phone. |
$15-$40
|
$240 allowance per year for preventive dental services |
|
Part D Prescription Drug Coverage |
||
Find a Drug - 2018 Comprehensive Medicare Part D Covered Drugs (Formulary)
Gold PPO with Part D offers the convenience of both medical and Part D prescription drug coverage together in one plan. Do not join a separate Part D plan for your prescription drug coverage. If you do, Medicare will disenroll you out of your MVP plan.
MVP's coverage for medically necessary Medicare Part D approved drugs includes: |
||
Initial Coverage Stage |
Retail Pharmacy (30 day supply) |
CVS Caremark Mail Order |
Tier 1 - Preferred Generic Drugs |
$0 | $0 |
Tier 2 - Generic Drugs |
$10 |
$20 |
Tier 3 - Preferred Brand Name Drugs |
$35 |
$70 |
Tier 4 - Non-Preferred Brand Name Drugs |
36% |
36% |
Tier 5 - Specialty Drugs |
33% |
Not Available |
Not all Part D drugs are available through the mail. |
||
Coverage Gap Stage |
Once your total drug expenses in 2018 reach $3,750, you will pay 44% for generic drugs, 35% for Medicare-contracted brands, 100% for non-Medicare contracted brands. You will continue to pay $0 for Tier 1 drugs. |
|
Catastrophic Coverage Stage |
When you have paid $5,000 out of pocket in 2018, your cost for prescriptions is reduced to the greater of 5% or $3.35 for generics and $8.35 for brand-name drugs. |
|
Part D drugs excluded from our Formulary must go through an exception process in order to be covered. If they are approved, they will be covered in Tier 4. |
||
Non-Part D drugs are not covered. |
||
Note: Costs for Part B drugs and supplies are 20%. Drugs purchased outside the U.S. are not Medicare approved and are not covered. |
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Out-of-network/non-contracted providers are under no obligation to treat MVP Health Plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
PPO members may see doctors within and outside the MVP network. However, with the exception of emergencies or urgent care, it will cost more to get care from OUT providers. You must use network pharmacies to access your prescription drug benefit.
Last Updated October 2017
